Provider Demographics
NPI:1215993787
Name:ROUDACHEVSKI, EVGUENI (DO)
Entity type:Individual
Prefix:
First Name:EVGUENI
Middle Name:
Last Name:ROUDACHEVSKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11912 KANIS ROAD
Mailing Address - Street 2:SUITE F-2
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3733
Mailing Address - Country:US
Mailing Address - Phone:501-227-8020
Mailing Address - Fax:501-227-8826
Practice Address - Street 1:11912 KANIS ROAD
Practice Address - Street 2:SUITE F-2
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3733
Practice Address - Country:US
Practice Address - Phone:501-227-8020
Practice Address - Fax:501-227-8826
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2957207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G78828Medicare UPIN
AR5L960Medicare ID - Type Unspecified